Hidden Valley Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Oak Hill, West Virginia.
- Location
- 422 23rd Street, Oak Hill, West Virginia 25901
- CMS Provider Number
- 515147
- Inspections on file
- 21
- Latest survey
- October 16, 2025
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Hidden Valley Center during CMS and state inspections, most recent first.
A resident with a history of aggressive behavior and bipolar disorder was not permitted to return to the facility after a hospital stay for behavioral evaluation. The facility refused readmission based on behaviors that occurred before hospitalization, did not issue a required discharge notice, failed to involve the resident or representative in discharge planning, and did not document that the resident's needs could not be met. Despite available beds, the facility made no efforts to accommodate the resident's return.
A resident was transferred to a hospital and, after remaining hospitalized beyond the bed-hold period, was denied readmission by the facility despite hospital documentation showing readiness for return. The facility did not provide the required written discharge notice to the resident, their representative, or the LTC ombudsman, nor did it coordinate discharge planning with the hospital or community services. This resulted in an involuntary discharge without proper notification or appeal rights.
Surveyors identified widespread deficiencies in environmental cleanliness and maintenance, including dirty and sticky floors, dirt and wax build-up around AC units and baseboards, missing or broken fixtures, and food debris in resident rooms and common areas. These issues were confirmed by the housekeeping and maintenance supervisors, as well as the DON and administrator.
A resident with dysphagia was nearly given regular consistency tea instead of the prescribed pudding-thick liquid by an LPN. The surveyor intervened to prevent the resident from consuming the incorrect liquid. The LPN did not measure the thickener properly, relying on visual assessment instead. This deficiency was identified as an Immediate Jeopardy situation, posing a significant risk of aspiration for the resident.
The facility failed to provide adequate nurse staffing, affecting all residents. Interviews revealed significant delays in assistance, with one resident waiting two hours after a call light was turned off. Staffing records showed insufficient nursing hours on specific days. Staff confirmed the shortage, citing hiring challenges and recent departures.
The facility failed to ensure RN coverage for 8 consecutive hours daily, as required. A review of staff postings and timecards showed no RN was scheduled or documented on specific dates. Although RN coverage was reported on some days, there was no proof of their presence. The Scheduling and Payroll Manager confirmed the lack of documentation and scheduling for RN coverage.
A facility failed to prevent further abuse and conduct a thorough investigation after a resident-to-resident altercation. One resident was hit by another's wheelchair, leading to a physical altercation and an abrasion. The facility separated the residents and modified the aggressor's wheelchair but did not document supervision or conduct interviews with other residents. The investigation lacked thoroughness and documentation.
The facility failed to ensure a safe environment, as one resident had unauthorized vitamins at her bedside, posing a risk to others, and another resident fell and fractured her hip due to not wearing non-skid socks as per her care plan. The LPN acknowledged the need for a physician's order for the vitamins, and the fall prevention measures were not properly implemented.
The facility failed to provide adequate hydration care to residents, as observed in three cases. A resident reported receiving very little water, another had to request water which was not consistently provided with ice, and a new admission experienced delays in receiving water. Despite care plans indicating risks for dehydration, the facility's hydration practices were insufficient, with water often not kept cool.
The facility failed to serve food that was palatable and at an appetizing temperature. Resident interviews indicated dissatisfaction with the food quality and temperature, with one resident stating the food is always cold, another frequently ordering cheeseburgers due to poor taste, and a third describing the food as tasteless and cold. A test tray showed the tuna melt at 112°F and potato wedges at 85°F, both below the desired temperature.
The facility failed to serve food safely and sanitarily. A resident was served Salisbury steak with gravy at an unsafe temperature, and the cook did not reheat it to the required 165°F. In the Alzheimer's unit, staff did not change gloves during meal service, risking cross-contamination.
The facility failed to maintain an effective infection control program, with improper storage of medical supplies under a sink and unsanitary meal service conditions. Items like COVID-19 test kits and clothes were stored in a soiled environment, and a resident was observed eating with a urinal on the table. These practices contravene infection control guidelines, highlighting lapses in maintaining sanitary conditions.
A resident's dignity was compromised when they were observed sitting on the toilet with both the bathroom and room doors open, visible from the hallway. The incident occurred while the Director of Rehab and a Speech Therapist were present, and the Speech Therapist was attempting to find toilet paper, highlighting a lapse in providing immediate and respectful care.
A facility failed to update a POST form for a resident who had the capacity to make their own health care decisions. Initially, the POST form was completed by a family member before the resident's admission. Upon admission, the resident confirmed the form represented their wishes, but after a physician determined the resident could make their own decisions, the form was not updated. This oversight was acknowledged by the Social Services Director.
A facility failed to provide timely and accurate notification of Medicare non-coverage to a resident. The Notice of Medicare Non-Coverage was improperly dated, indicating an error in the notification process. The resident's services were scheduled to end, but the NOMNC was incorrectly dated, which was acknowledged by the Office Manager. This error had the potential to impact the resident's awareness of their appeal rights.
A resident reported being unable to open a window due to a missing screen, which they had requested to be replaced multiple times. An observation confirmed the absence of the screen, and the Maintenance Director acknowledged the issue.
A facility failed to ensure an accurate MDS assessment for a resident, incorrectly coding a fall with injury despite the resident having only one fall without injury. This was confirmed through medical record review and a nurse interview.
A facility failed to accurately complete a PASSAR for a resident, omitting diagnoses of Schizophrenia and Epilepsy. This oversight was discovered during a record review, and the Social Worker acknowledged missing these diagnoses during an audit.
The facility failed to implement care plans for two residents, one with a history of falls and another with depression. A resident with a hip fracture was found wearing non-skid socks, contrary to their care plan. Another resident with depression had no care plan addressing their mental health needs, as confirmed by the social worker.
A resident who required assistance for activities of daily living due to a leg fracture did not receive scheduled showers, impacting their personal hygiene. The resident preferred showers over bed baths, but on one occasion, a bed bath was given without documentation of a shower refusal. The DON confirmed that refusals should be documented, but no further explanation was provided.
A facility failed to provide adequate pressure ulcer care for a resident with a history of skin damage. The resident returned from the hospital with a deep tissue injury and developed a bed sore along the sacrum. Inconsistencies in treatment and monitoring were noted, with a lack of formal assessment and failure to enter treatment orders. An observation revealed a wrinkled dressing and an unstageable pressure ulcer, highlighting deficiencies in care.
A facility failed to maintain accurate medical records when an LPN documented that a resident consumed 100% of a supplement, while it was observed to be three-quarters full. The LPN confirmed the inaccuracy upon review of the MAR and the Medication Administration Audit report.
The facility failed to follow physician orders for a resident to have blood sugar checks three times a day. The resident's medical record showed no blood sugar readings for 13 days, and the Unit Manager confirmed the absence of documentation, indicating a nurse had edited the order, leading to uncertainty about the checks being performed.
The facility failed to ensure a safe environment by not adhering to prescribed transfer methods for a resident with paraplegia and not implementing a fall intervention for another resident with a history of falls. Documentation and observations revealed significant lapses in following care plans, leading to unsafe conditions.
The facility failed to follow professional standards for food service safety when an Activities Assistant was observed distributing ice cream in open containers without lids or coverings. The Activities Director acknowledged the mistake.
The facility failed to maintain an infection prevention and control program, as evidenced by unsanitary conditions in the memory unit and other areas. Observations included soiled clothing and washcloths with dark substances in the bathtub and shower, and a black substance on a spray nozzle. The IC RN acknowledged repeated staff education on this issue.
The facility failed to provide a dignified dining experience for a resident who was served 30 minutes after others due to staff shortage. Additionally, another resident was observed using a bedside commode without privacy measures in place, contrary to her care plan.
The facility failed to implement a care plan intervention for a resident with a history of falls. The care plan required the left side of the bed to be against the wall, but during an observation, the bed was found positioned incorrectly, with the head of the bed against the wall and fall mats on either side.
The facility failed to update the care plan for a resident using a bedside commode, resulting in a lack of privacy. The resident was observed using the commode in front of an open window with no privacy measures in place. Medical records showed the care plan was not revised to include the commode use.
A resident was not fed her noontime meal for 30 minutes after other residents were served due to insufficient staff deployment. The resident was left alone, simulating eating, while staff assisted others. The issue arose because the DON was on vacation, and available staff were not called to help.
The facility failed to ensure a resident's medical record was accurate, incorrectly documenting a significant weight gain of 5.1 percent when the actual gain was only half a pound. This discrepancy was confirmed by facility staff.
The facility failed to post accurate nursing staffing data, specifically regarding the total number of CNAs and their actual hours worked. This issue was identified on two separate days, with discrepancies confirmed by the Administrator during interviews.
Failure to Permit Resident Readmission After Hospitalization Due to Behavioral Issues
Penalty
Summary
The facility failed to ensure that a resident was permitted to return following a hospitalization for behavioral evaluation. The resident, who had a history of aggressive behavior and bipolar disorder, was transferred to the hospital after exhibiting increased agitation, verbal aggression, sexually inappropriate comments, and threats toward staff. Facility staff addressed these behaviors through 1:1 observation, medication adjustments, and staff re-education. Despite documentation indicating that the resident's return was anticipated, the facility did not readmit the resident after hospitalization. Interviews with the hospital care manager and the ombudsman revealed that the facility refused to accept the resident back, citing behaviors that occurred prior to the hospitalization. The facility did not provide a discharge notice that met federal requirements, did not involve the resident or their representative in discharge planning, did not document that the resident's needs could not be met, and did not attempt to make reasonable accommodations for the resident's return. Bed census records confirmed that a bed was available at the time the resident's hospital bed-hold expired. The administrator confirmed the decision to decline readmission was based on the resident's prior behaviors and acknowledged that no discharge notice was issued.
Failure to Provide Required Written Notice and Appeal Rights Prior to Discharge and Refusal of Readmission
Penalty
Summary
The facility failed to provide the required written notice to a resident, their representative, and the long-term care ombudsman prior to discharging the resident and refusing readmission after hospitalization. Record review showed that the resident was transferred to the hospital and remained there beyond the bed-hold period, but hospital documentation indicated the resident was ready to return. Despite this, the facility declined readmission without issuing a written discharge notice that included the reason for discharge, effective date, and appeal rights. There was also no evidence that the ombudsman received a copy of the notice or that discharge planning was coordinated with the hospital and community services. Interviews with the hospital care manager, ombudsman, and facility administrator confirmed that no written notice was provided prior to the refusal of readmission, resulting in an involuntary discharge without the required notifications and denial of appeal rights.
Widespread Environmental Cleanliness and Maintenance Deficiencies
Penalty
Summary
Surveyors observed that the facility failed to maintain a comfortable and sanitary environment for its residents, staff, and the public. During a facility tour, multiple resident rooms were found with various cleanliness and maintenance issues, including brown and dirty rings around the base of toilets, missing toilet paper roll holders, broken window slats, broken or off-track wardrobe drawers, and numerous dry wall mud patches on walls. Additional observations included dirty and sticky floors, dirt and wax build-up around air conditioning units and baseboards, cobwebs in corners, food debris on floors and around beds, and broken or missing tiles. The painted finish was also noted to be coming off handrails in the Alzheimer's/Dementia Unit, and the common area railing had visible dirt and debris. In some rooms, air conditioning units lacked filters and had dirty coils, and bed linens were found dirty on at least one bed. These findings were confirmed through interviews with the Housekeeping Supervisor and Maintenance Supervisor, who both verified the observations. The Administrator and Director of Nursing also acknowledged the findings during the exit interview. The issues identified were not isolated to a small number of residents, as the observations spanned numerous rooms and common areas, affecting a significant portion of the facility's census of 74 residents.
Failure to Provide Correct Liquid Consistency for Resident
Penalty
Summary
The facility failed to ensure that Resident #21 received liquids at the appropriate thickness as ordered by the physician. The resident, who had a medical order for spoon-thick liquids due to dysphagia, was nearly given regular consistency tea by an LPN during a meal. The surveyor intervened to prevent the resident from consuming the incorrect liquid consistency. The resident's medical record indicated a need for pudding-thick liquids, and the resident's door was marked with a sticker indicating this requirement. Despite these indicators, the LPN attempted to serve the resident a drink that was not properly thickened. The LPN responsible for assisting Resident #21 with her meal did not follow the proper procedure for thickening the liquid. After being stopped by the surveyor, the LPN attempted to thicken the tea using a bowl of thickener but did not measure the appropriate amount as directed by the manufacturer. The LPN relied on visual assessment rather than precise measurement, resulting in a liquid that was still not at the required pudding-thick consistency. The DON confirmed that staff typically add thickener until the liquid looks right, without using specific measurements. This deficiency was identified as an Immediate Jeopardy situation by the State Agency, as it posed a significant risk of aspiration for Resident #21. The facility's failure to provide the correct liquid consistency had the potential to affect other residents receiving thickened liquids, although at the time of the survey, only two other residents required thickened liquids. The incident highlighted a lack of adherence to physician orders and proper procedures for preparing thickened liquids, which could have led to serious health consequences for the resident.
Insufficient Nurse Staffing in Facility
Penalty
Summary
The facility failed to provide sufficient nurse staffing numbers, which had the potential to affect all residents. During interviews, several residents reported significant delays in receiving assistance. One resident mentioned that staff would turn off her call light and promise to return, but she had to wait for two hours. Another resident reported waiting from 4:30 PM to 7:30 PM for assistance with changing her brief due to low staff numbers. A third resident stated that he usually had to wait half an hour for his call light to be answered, attributing the delay to insufficient staffing. A review of the Daily Nurse Staffing Form revealed that the facility did not have sufficient staffing on specific days, with nursing hours falling short of the required levels. Interviews with staff members corroborated these findings, with a nurse aide reporting that there were sometimes only two aides during the day and one at night, which was inadequate to meet residents' needs. The Scheduling and Payroll Manager acknowledged the staffing issues, citing difficulties in hiring new aides and recent staff departures as contributing factors to the shortage.
Failure to Ensure RN Coverage 8 Hours Daily
Penalty
Summary
The facility failed to ensure that a Registered Nurse (RN) was available for 8 consecutive hours a day, 7 days a week, which is a requirement for the facility's operation. This deficiency was identified through a review of staff postings and timecards, which revealed that on specific dates, including 09/14/24, 09/28/24, 11/19/23, and 12/03/24, there was no RN scheduled or documented as working. Additionally, although RN coverage was reported on 09/15/24 and 09/22/24, there was no proof of their presence in timecards, notes, or medication administration records. An interview with the Scheduling and Payroll Manager confirmed the lack of documentation and scheduling for RN coverage on these dates, acknowledging the absence of an RN on duty as required.
Incomplete Investigation of Resident-to-Resident Abuse
Penalty
Summary
The facility failed to prevent potential further abuse of all residents while investigating an allegation of resident-to-resident abuse and did not complete a thorough investigation. The incident involved two residents, where one resident was hit by another resident's wheelchair, leading to a physical altercation. The resident who was hit reported that this was not the first time the other resident had hit him with his wheelchair. The altercation resulted in an abrasion to the upper lip of the resident who was hit, although he denied experiencing pain or discomfort. The facility's interventions included separating the two residents and modifying the aggressor's wheelchair to make it slower. The investigation into the incident was incomplete, as the social worker admitted that there was no documentation of the one-on-one supervision provided to the aggressor during the investigation. Additionally, no interviews or audits were conducted with other residents to determine if anyone else was affected by the aggressor's behavior. The facility also failed to implement interventions to address the aggressor's behaviors, despite his history of running into others with his wheelchair. Notifications were made, and both residents were assessed by nursing, but the investigation lacked thoroughness and documentation.
Deficiency in Accident Hazard Prevention and Supervision
Penalty
Summary
The facility failed to maintain a resident environment free from accident hazards, as evidenced by two separate incidents involving residents. In the first incident, a resident was found with a bottle of Centrum Women's vitamins at her bedside, which she preferred over the facility-provided vitamins. This posed a risk to other residents, particularly those who might wander into her room and consume the vitamins, potentially leading to symptoms such as stomach pain, nausea, vomiting, and diarrhea. The LPN on duty acknowledged that residents should not have medications at their bedside and planned to obtain a physician's order for the vitamins. In the second incident, another resident experienced a fall resulting in a right hip fracture. The resident was not wearing non-skid socks at the time of the fall, despite having a care plan that included the use of non-skid footwear to prevent falls. An observation conducted later revealed that the resident was wearing fuzzy socks that were not non-skid, indicating a failure to adhere to the fall prevention interventions outlined in the care plan. This oversight contributed to the resident's fall and subsequent injury.
Inadequate Hydration Care for Residents
Penalty
Summary
The facility failed to provide adequate hydration care and services to residents, as observed in the cases of three residents. Resident #68, who was cognitively intact, reported receiving very little water and was observed without any beverage containers in his room. Despite being at risk for dehydration due to diuretic use, his care plan was not effectively implemented to ensure adequate fluid intake. Similarly, Resident #59, with mild cognitive impairment and at risk for dehydration due to constipation, was found with an empty pitcher and had to request water, which was not consistently provided with ice or kept cool. Resident #180, a new admission, also reported delays in receiving water, having once waited two hours for it. Although his care plan indicated a risk for dehydration related to diuretic use, the facility's hydration practices were insufficient. Nursing assistants reported providing water and ice at specific times, but observations showed that residents often had water that was not cool, indicating a lack of adherence to the facility's policy on hydration care and services.
Deficiency in Food Temperature and Palatability
Penalty
Summary
The facility failed to serve food that was palatable and at an appetizing temperature, as evidenced by resident interviews and test tray temperature measurements. Resident interviews revealed dissatisfaction with the food quality and temperature, with one resident stating the food is always cold and not good, another resident frequently ordering cheeseburgers due to poor taste, and a third resident describing the food as tasteless and cold upon arrival. A test tray conducted by the Certified Dietary Manager showed that the tuna melt was at 112 degrees Fahrenheit and the potato wedges at 85 degrees Fahrenheit, both of which were acknowledged by the manager as being below the desired temperature. This deficiency has the potential to affect more than a limited number of residents, with a facility census of 77.
Food Safety and Sanitation Deficiencies in Meal Service
Penalty
Summary
The facility failed to ensure food was served in a safe and sanitary manner during a meal service observation. During the noon meal service, a resident was served Salisbury steak with gravy that had been sitting on the stove cooling. The temperature of the gravy was measured at 122 degrees Fahrenheit, which is below the safe serving temperature. The cook acknowledged that the gravy was served from the pot that had not been reheated properly. Although the cook reheated the gravy to 150 degrees Fahrenheit, it was still below the required reheating temperature of 165 degrees Fahrenheit as confirmed by the Certified Dietary Manager. In a separate observation in the Alzheimer's unit, staff were found to be serving meal trays to residents without changing their gloves throughout the entire meal pass process. A Nurse Aide confirmed that this was the usual practice unless they needed to feed a resident. This practice raises concerns about cross-contamination and the maintenance of sanitary conditions during meal service.
Infection Control Deficiencies in Storage and Meal Service
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by improper storage practices and unsanitary conditions observed during a survey. In the medication preparation room of the memory unit, items were improperly stored under a sink, which is considered a soiled environment. Specifically, three BinaxNOW COVID-19 testing boxes, a bag containing tools, and a pile of clothes were found under the sink. The LPN present during the inspection was unaware of the clothes' presence and acknowledged the need to remove and properly store these items. The improper storage of medical supplies and personal items under the sink contravenes guidelines from John Hopkins Medicine and the CDC, which state that medical and surgical supplies should not be stored in areas where they can become wet or contaminated. Additionally, during a meal service observation, a resident was found eating with a urinal placed on the overbed table beside his meal tray. The urinal was partially filled with urine, and the resident was observed holding it with one hand while eating with the other. The Nursing Home Administrator was informed of the situation and attempted to address it by removing the urinal, but the resident continued to handle the urinal during the meal. This incident highlights a lapse in maintaining sanitary conditions during meal times, which is crucial for infection control and resident safety.
Resident's Dignity Compromised During Restroom Use
Penalty
Summary
The facility failed to ensure a dignified experience for Resident #44 while using the restroom. On the morning of September 25, 2024, a surveyor observed Resident #44 sitting on the toilet with her pants down, visible from the hallway due to both the bathroom and room doors being open. This lack of privacy was noted as the Director of Rehab and a Speech Therapist were present across the hall. When the surveyor inquired about assistance for the resident, the Speech Therapist mentioned that they were trying to find some toilet paper, indicating a lapse in providing immediate and respectful care to the resident.
Failure to Update POST Form for Resident with Decision-Making Capacity
Penalty
Summary
The facility failed to ensure that residents were given the opportunity to make decisions regarding end-of-life care, specifically in the case of a resident who had the capacity to make their own health care decisions. The deficiency involved a resident whose medical records included a Physician Orders for Scope of Treatment (POST) form completed by a family member prior to the resident's admission. Upon admission, the Social Services Director reviewed the POST form with the resident, who confirmed that it represented their wishes. However, after a physician determined that the resident had the capacity to make their own medical decisions, the POST form was not updated to reflect the resident's own decisions, as it had been completed by a family member. This oversight was acknowledged by the Social Services Director during the survey, indicating a failure to update the POST form in accordance with the resident's capacity to make independent health care decisions.
Improperly Dated Medicare Non-Coverage Notice
Penalty
Summary
The facility failed to provide timely and accurate notification of Medicare non-coverage to a resident, which is a requirement for beneficiary protection. Specifically, the Notice of Medicare Non-Coverage (NOMNC) for a resident was improperly dated, indicating an error in the notification process. The resident's services were scheduled to end on 5/28/24, but the NOMNC was incorrectly dated as 03/23/24 instead of the correct date, 05/23/24. This error was acknowledged by the Office Manager during an interview, who confirmed the mistake in the date. The resident's representative was notified by phone on 03/23/24, but the incorrect dating of the NOMNC had the potential to impact the resident's awareness of their appeal rights before the end of Medicare-covered services.
Missing Window Screen in Resident's Room
Penalty
Summary
The facility failed to provide a safe, clean, and comfortable homelike environment for a resident, as evidenced by the absence of a screen in one of the windows in the resident's room. During an interview, the resident expressed that they could not open the window due to the missing screen and had requested a replacement multiple times without success. An observation confirmed that one of the four windows in the resident's room lacked a screen. The Maintenance Director acknowledged the missing screen and indicated an intention to address the issue.
Inaccurate MDS Assessment for Resident Fall
Penalty
Summary
The facility failed to ensure an accurate assessment for a resident in the area of falls with injury. During the survey, it was found that the Minimum Data Set (MDS) for a resident was incorrectly coded to indicate a fall with injury, despite the resident having only one fall without injury since the last MDS assessment. This discrepancy was confirmed through a review of the resident's medical record and an interview with a registered nurse, who acknowledged that the MDS was inaccurate and should not have included a fall with injury.
Inaccurate PASSAR Completion for Resident
Penalty
Summary
The facility failed to accurately complete a Pre-admissions Screening and Resident Review (PASSAR) for a resident, which is a requirement during the Long-Term Care Survey Process. The deficiency was identified during a record review on September 23, 2024, which revealed that the resident had diagnoses of Schizophrenia and Epilepsy. However, these diagnoses were not included in the most recent PASSAR completed on February 17, 2022. During an interview, the Social Worker admitted to missing these diagnoses when conducting an audit of the PASSARs, confirming the oversight.
Deficiencies in Care Plan Implementation for Falls and Depression
Penalty
Summary
The facility failed to develop and implement adequate care plans for two residents, leading to deficiencies in addressing fall interventions and depression. For one resident, who had a history of falls and a recent hip fracture, the care plan included interventions such as providing non-skid footwear and maintaining a clutter-free environment. However, during an observation, the resident was found wearing fuzzy socks that were not non-skid, contrary to the care plan's requirements. A nurse aide confirmed the use of non-skid socks was not adhered to, indicating a lapse in implementing the prescribed interventions. Another resident, diagnosed with depression and prescribed Mirtazapine, did not have a care plan addressing their mental health needs. The social worker acknowledged the absence of a care plan for depression, attributing it to not being present when the resident was admitted. This oversight highlights a failure in developing a comprehensive care plan to address the resident's diagnosed condition, leaving their mental health needs unaddressed.
Failure to Provide Scheduled Showers for Resident
Penalty
Summary
The facility failed to ensure that a resident who was unable to carry out activities of daily living received the necessary services to maintain good personal hygiene. This deficiency was identified during an interview with a resident who reported not receiving twice-weekly showers as scheduled. The resident, who required substantial assistance for bathing due to a leg fracture, expressed a preference for showers over bed baths. The facility's shower schedule indicated that the resident was to receive showers on Tuesday and Friday evenings. Upon review of the resident's shower records for the past 30 days, it was found that the resident did not receive a shower on one scheduled day, and there was no documentation of a refusal. Specifically, on 09/13/24, the resident received a bed bath instead of a shower, with no refusal documented. The Director of Nursing confirmed that shower refusals should be documented in both the nurses' notes and the NA task documentation report, but no further information was provided to explain the discrepancy.
Failure to Provide Adequate Pressure Ulcer Care
Penalty
Summary
The facility failed to provide pressure ulcer treatment in accordance with professional standards of care for a resident with a history of moisture-associated skin damage and incontinence-associated dermatitis. The resident returned to the facility from the hospital with a deep tissue injury on the buttocks, which was noted in the nurse report form. Despite having physician's orders for skin care, the resident developed a bed sore along the sacrum, as noted by an orthopedic physician during a follow-up visit. The resident's medical records showed inconsistencies in the treatment and monitoring of the pressure ulcer. The resident's weekly skin and wound evaluations indicated changes in the condition of the gluteal fold, with measurements fluctuating over time. However, there was a lack of formal assessment between certain dates, and the treatment orders were not consistently followed or updated. The resident was seen in a wound care clinic, but the facility failed to enter an order for the recommended treatment. During an observation, the resident was found to have a wrinkled and loose adhesive dressing on the sacral/coccyx area, with a small open area underneath. The resident complained of pain, and a change in condition evaluation revealed an unstageable pressure ulcer. The Director of Nursing confirmed the lack of formal assessment and the failure to enter treatment orders as recommended by the wound care clinic. This deficiency in care had the potential to affect the resident's health and well-being.
Inaccurate Documentation of Supplement Consumption
Penalty
Summary
The facility failed to ensure the accuracy and completeness of a resident's medical record. During a survey, it was observed that a resident was sitting in the TV lounge with a supplement that was still three-quarters full, despite the medical record indicating that the resident had consumed 100% of it. An LPN confirmed that the medication administration record (MAR) inaccurately reflected full consumption of the supplement. The LPN acknowledged documenting the consumption before the resident had actually finished the supplement, which was still mostly full at the time of observation. This discrepancy was further confirmed by a review of the Medication Administration Audit report.
Failure to Follow Physician Orders for Blood Sugar Monitoring
Penalty
Summary
The facility failed to follow physician orders for a resident to have blood sugar checks three times a day. A review of the resident's medical record revealed a physician order for Accu Check TID, with instructions to notify the physician if blood sugar levels were less than 70 or greater than 450. This order was dated 03/18/24 and was current at the time of the review. However, the facility had not obtained a blood sugar reading since 04/09/24 at 10:20 am, resulting in a lapse of 13 days without monitoring. During an interview, the Unit Manager confirmed the absence of documented blood sugar readings and indicated that a nurse had edited the order, removing the supplement documentation, leading to uncertainty about whether the checks were being performed.
Failure to Ensure Safe Transfer and Fall Prevention
Penalty
Summary
The facility failed to ensure the resident environment was free from accident hazards and provided adequate supervision to prevent accidents. Resident #1, who had a diagnosis of paraplegia and contractures at the knees and hips, was assessed to require a total body lift with a two-person assist for transfers. However, documentation revealed that Resident #1 was transferred incorrectly 113 out of 138 times during his stay, with instances of being transferred independently, with supervision, or with the assistance of only one person. This inconsistency in following the prescribed transfer method was confirmed through record review and staff interviews, indicating a significant lapse in adhering to the resident's care plan and safety requirements. For Resident #4, who had a history of falls and was at risk for further falls due to impaired mobility and Huntington's Disease, the facility failed to implement a specified fall intervention. The care plan included an intervention to place the left side of the bed against the wall, which was added to the care plan but not followed. An observation revealed that the resident's bed was not positioned against the wall as required, and fall mats were placed on either side of the bed instead. This failure to implement the fall intervention as outlined in the care plan further highlights the facility's deficiency in maintaining a safe environment for its residents.
Improper Food Service Safety Practices
Penalty
Summary
The facility failed to distribute and serve food in accordance with professional standards for food service safety. During a tour of the facility, an Activities Assistant (AA) was observed pushing a cart with five open containers of vanilla ice cream down Unit A. The AA stated that she was serving the residents ice cream in their rooms and had been instructed to prepare the open containers without lids or coverings. The Activities Director (AD) acknowledged that the open containers of ice cream should not be on the floor without being covered or having lids on them.
Infection Control Deficiencies in Memory Unit and Shower Room
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program, as evidenced by multiple observations of unsanitary conditions in the memory unit and other areas. On 04/24/24, a walk-in bathtub in the memory unit was found to contain two items of clothing with a dark brown substance on them. Additionally, the shower in the same unit had two wet washcloths on the floor, one of which also had a dark brown substance. The hand-held spray nozzle of the walk-in bathtub was observed to have a black substance coming out of the holes. These observations were confirmed by the memory unit Director, who acknowledged that the items should not be there and was unsure of the nature of the substances found. Further, on 04/22/24, a soiled towel and washcloth were found lying on the floor of Unit A's small shower room. The Infection Control Registered Nurse (IC RN) acknowledged the presence of the soiled linens and stated that staff had been educated multiple times about not leaving soiled linens on the floor. She picked up the soiled items and placed them in a bag. These findings indicate a failure to maintain a safe, sanitary, and comfortable environment, potentially affecting more than an isolated number of residents.
Failure to Ensure Dignified Dining and Privacy for Residents
Penalty
Summary
The facility failed to ensure Resident #19 had a dignified dining experience during the noon meal. Resident #19 was seated alone in the back dining room and was not served her meal until 30 minutes after the last resident in the same dining room had been served. During this time, Resident #19 was observed talking to herself and simulating eating imaginary items. The delay was attributed to a shortage of staff, as the Director of Nursing was on vacation, and the available staff did not seek additional help to feed Resident #19 promptly. The Nursing Home Administrator acknowledged that there were enough staff available to assist if they had been called upon. Additionally, the facility failed to ensure privacy for Resident #18 while she was using a bedside commode. Resident #18 was observed using the commode in front of an open window with the blinds not pulled, the room door open, and no privacy curtain drawn. LPN #76, who was outside the room, acknowledged the lack of privacy and instructed a CNA to ensure the blinds and curtains were used in the future. Resident #18's care plan, dated 01/30/24, indicated that she should be provided with privacy and comfort, which was not adhered to during this incident. The Unit Manager confirmed that the staff should have ensured privacy for Resident #18 as per her care plan.
Failure to Implement Accident Care Plan for Resident
Penalty
Summary
The facility failed to implement Resident #4's accident care plan. Resident #4, who has a history of falls and is at risk for further falls due to impaired mobility, incontinence, and Huntington's Disease, had a care plan intervention that required the left side of the bed to be against the wall. This intervention was added to the care plan on 04/05/24. However, during an observation on 04/23/24, it was found that the resident's bed was not positioned against the wall as required. Instead, the head of the bed was against the wall, and fall mats were placed on either side of the bed. This discrepancy was noted in the presence of the Nursing Home Administrator.
Failure to Revise Care Plan for Bedside Commode Use
Penalty
Summary
The facility failed to revise the comprehensive care plan for Resident #18 to include the use of a bedside commode. On 04/23/24 at 9:06 AM, Resident #18 was observed using a bedside commode in front of an open window with the blinds not pulled, the room door open, and no privacy curtain pulled. The resident stood up and wiped herself in full view of the neighboring residential area. LPN #76, who was outside the room, acknowledged the lack of privacy and instructed CNA #5 to ensure privacy measures were taken. A medical record review at 10:00 AM revealed that Resident #18 was care planned for incontinence but not for the use of a bedside commode. UM LPN #38 confirmed the care plan had not been updated when the bedside commode was introduced.
Failure to Timely Feed Resident Due to Insufficient Staff Deployment
Penalty
Summary
The facility failed to deploy available staff in a manner that ensured Resident #19 was fed her noontime meal in a timely manner. During an observation of the lunch meal, Resident #19 was noted to be sitting alone at a table in the back dining room. While seven other residents were served their meals by 12:00 PM, Resident #19's tray was set aside by an Activity Assistant after being told by a Nurse Aide to wait until they were done feeding other residents. Resident #19 was left without assistance for 30 minutes, during which she was observed talking to herself and simulating eating by picking at the table and moving her hand to her mouth. At 12:30 PM, a Licensed Practical Nurse asked the Activity Assistant to get a new tray for Resident #19 and proceeded to feed her. When questioned, the LPN acknowledged the lack of sufficient staff to assist with feeding during the noon meal, noting that the Director of Nursing, who was usually present, was on vacation. An interview with the Nursing Home Administrator and other staff confirmed that there were enough available staff in the facility who could have been called to assist, but this was not done, resulting in Resident #19 being left without her meal for an extended period.
Inaccurate Nutritional Assessment
Penalty
Summary
The facility failed to ensure that Resident #2's medical record was complete and accurate. A review of the resident's nutritional assessment indicated a significant weight gain of 5.1 percent over one month, which was incorrect. The resident's actual weight gain was only half a pound, from 140.5 pounds to 141 pounds. This discrepancy was confirmed through an interview with the Nursing Home Administrator, the Nurse Practice Educator, and the Unit Manager.
Inaccurate Nursing Staffing Data Posting
Penalty
Summary
The facility failed to post accurate data on the nursing staffing data forms, specifically regarding the total number of staff and the actual hours worked by certified nursing assistants (CNAs). This issue was identified for two of the nine daily nursing staffing forms reviewed, specifically on 03/09/24 and 03/10/24. On 03/09/24, the staffing posting form did not document the CNA staffing numbers or the scheduled hours for the 07:00 AM to 03:00 PM shift. The Administrator acknowledged this discrepancy during an interview on 04/23/24. On 03/10/24, the staffing posting form inaccurately identified the total number of CNAs and the hours worked for both the 07:00 AM to 03:00 PM and the 03:00 PM to 11:00 PM shifts. The form indicated three CNAs with a total of 24 hours for the morning shift, while the time detail report showed four CNAs with 32 hours worked. For the evening shift, the form documented 5.5 CNAs with 27 hours, whereas the time detail report identified six CNAs with 22 hours worked. The Administrator confirmed these inaccuracies during an interview on 04/24/24.
Latest citations in West Virginia
A deficiency occurred when a lunch tray on A Hall was found to be served below required hot-holding temperature standards. During a survey, a random tray containing mashed potatoes and gravy with steak was tested by the Traveling Dietary Manager in the presence of the Administrator, and both food items measured 110°F, which did not meet required serving temperatures. The Traveling Dietary Manager and the Administrator each confirmed that the food temperature was not at the required level, and the administrative team later acknowledged this deficiency.
Surveyors found that the facility failed to provide residents with consistent and accurate readily available menus reflecting their food preferences. The Traveling Dietary Manager reported that residents could choose from multiple egg preparations, but these options were not listed on the posted menu available to residents. Additionally, the “always available” menu used in the kitchen did not match the menu provided to residents, and this discrepancy was confirmed by the Traveling Dietary Manager. The issue was identified on all menus reviewed and had the potential to affect many residents in the facility.
The facility failed to follow its abuse reporting policy when a cognitively intact resident reported that two nurses were frequently sleeping on duty and later provided an audio recording of a nurse calling the resident a "jerk." The allegation was reported by the resident to an LPN and then to an RN Infection Preventionist, but the Administrator remained unaware until the survey, and the incident was not reported to authorities within the required 2-hour timeframe. In a separate case, another resident had a verbal abuse incident reported to the state, but the facility did not complete or submit the required 5-day follow-up report, and the Administrator confirmed there was no record of that follow-up.
A resident reported unknown charges on her debit card and alleged that a former roommate had used the card without permission, estimating losses of several hundred dollars. The facility documented initial steps such as notifying external agencies, involving law enforcement, cancelling the card, separating the roommates, and assisting the resident in obtaining bank statements. However, the facility did not maintain or retain key documentation, including copies of bank statements, the total amount of funds involved, or clear follow‑up on the status and outcome of the allegation. The resident reported not receiving updates, and the BOM acknowledged that the facility lacked the resident’s financial records because they had been turned over to law enforcement and were not requested or reviewed by facility staff until shortly before the survey, resulting in an incomplete internal investigation record of the alleged misappropriation.
A resident who was cognitively intact but lacked capacity for health care decisions left the facility after breakfast and morning meds. An activities assistant saw the resident walking outside and reported this to the Manager on Duty, but no effective action was taken to verify the resident’s whereabouts or initiate a search. Nursing staff later assumed the resident was in the bathroom or out smoking when he was not in his room at mid-morning and lunchtime. The facility did not recognize the resident as missing or begin search efforts until hours later, during which time the resident hitchhiked and accepted a ride from a stranger in the community. Surveyors determined that staff had witnessed the resident outside but failed to intervene or report effectively, and that the facility remained unaware of the resident’s absence for several hours, resulting in an Immediate Jeopardy finding for neglect.
A resident who is blind and requires specific instruction during ambulation was transferred from therapy to Restorative with documented recommendations to ambulate using a walker, gait belt, and a wheelchair behind her, along with ROM and strengthening exercises. Despite a physician’s order for a Restorative Nursing Program for ambulation and ROM and the therapy recommendations communicated via an Excel spreadsheet, Restorative staff ambulated the resident without a gait belt. The resident reported becoming tired while walking, with a wheelchair behind her but not close enough, and then falling hard. She and a PTA both stated that no gait belt was used. The fall resulted in fractures to the resident’s left distal femur and right distal femur/knee area, with osteopenia noted, and the DON acknowledged that therapy recommendations had not been carried over for Restorative staff to follow.
A resident experienced multiple leg fractures after a fall, resulting in a significant change in condition and non–weight-bearing status. Although the MDS reflected that it was important for the resident to participate in group activities, favorite pastimes, and church services, the activity care plan was not revised after the injury to address her new limitations. The existing plan listed numerous preferred activities such as resident council, food committee, religious services, music, gardening, and in-room pursuits, but no new individualized interventions were added, and documentation showed only two 1:1 visits after her return from the hospital. The resident reported she could no longer get into her wheelchair, attend council or church, or join groups she enjoyed, and stated that activity staff did not visit often, while the Director of Recreation confirmed she had not attended groups since the injury and that in-room social visits were not consistently documented, resulting in a decline in activity participation and social isolation.
A resident was discharged to a motel with home health services, a wheelchair, medications, and a follow‑up medical appointment arranged, and received education on medications, blood glucose monitoring, emergency response, and home health services. Discharge planning discussions and a referral to the Take Me Home program were documented, and the facility agreed to pay for an initial period of the motel stay. However, record review and staff interviews confirmed that the resident was not given the required 30‑day written discharge notice prior to leaving, limiting the resident’s ability to prepare for discharge and exercise discharge‑related rights.
A resident sustained multiple lower extremity fractures after a fall, resulting in hospitalization, non-weight-bearing status, and loss of prior functional abilities such as standing, pivoting, and walking with therapy. Before the fall, the resident actively participated in out-of-room activities including Resident Council, food committee, church, and socials, but after returning from the hospital she no longer attended group activities and had only two documented 1:1 visits. Despite an MDS indicating a significant change in status and clear changes in activity participation, the activity care plan—last revised months earlier—was not updated with new interventions to address her altered condition and in-room activity needs, as confirmed by record review and staff interviews.
A resident with intact cognition and a history of active participation in group activities, Resident Council, and church sustained bilateral lower-extremity fractures and returned from the hospital non–weight bearing. The MDS significant change assessment and the activity care plan documented that group involvement, church services, and various preferred activities were important to the resident, yet no new interventions were added to the care plan after the change in condition. Activity participation records showed that the resident had no out-of-room activities and only two documented 1:1 visits, while the Director of Recreation acknowledged that group attendance had stopped and that in-room social visits were not consistently documented. The resident reported feeling unable to attend her usual groups, Resident Council, or church and stated that activity staff did not visit often, leading surveyors to find that the facility failed to provide an activities program that met her needs and interests following her significant change.
Improper Hot Food Serving Temperatures During Lunch Service
Penalty
Summary
The facility failed to provide resident meals at proper serving temperature during a lunch meal service on A Hall. On 03/24/26 at approximately 12:10 PM, a surveyor had a random lunch tray on A Hall temperature-tested by the Traveling Dietary Manager, with the facility Administrator present. The tested items—mashed potatoes and gravy with steak—were both measured at 110°F. During an interview at approximately 12:15 PM, the Traveling Dietary Manager confirmed that the food did not meet the required serving temperature, and at approximately 12:16 PM, the Administrator also confirmed that the food did not meet the required serving temperature. This deficiency was acknowledged by the facility’s administrative team upon survey exit on 03/25/26 at approximately 4:00 PM. No additional resident-specific clinical information or conditions were provided in the report.
Inconsistent Readily Available Menus for Resident Food Preferences
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to provide residents with consistent and accurate information about readily available menu items that accommodate resident preferences. During document review and staff interviews, the Traveling Dietary Manager stated that residents could choose from several egg preparations (omelet, scrambled eggs, hard-boiled egg, or hard-fried egg) as part of the facility’s readily available items. However, the posted readily available menu accessible to residents did not list these egg options. Additionally, the “always available” menu used in the kitchen did not match the menu provided to residents, and the Traveling Dietary Manager confirmed that the readily available menus did not correlate. This inconsistency was found on 2 of 2 menus reviewed and had the potential to affect more than a limited number of residents in a facility with a census of 90. On a subsequent interview, the facility Administrator acknowledged the deficiency during the exit interview.
Failure to Timely Report Verbal Abuse Allegation and Submit Required 5-Day Follow-Up
Penalty
Summary
The facility failed to follow its abuse prohibition policy requiring that allegations of abuse be reported to the proper authorities within two hours of identification and that required follow-up reports be completed. The policy defined verbal abuse as the willful use of disparaging or derogatory language toward residents or within their hearing. A cognitively intact resident with a BIMS score of 15 reported that two nurses who worked Monday through Thursday were "always sleeping" and that, after he reported this to administration, one of the nurses called him a "jerk." The resident had an audio recording dated 03/11/26 capturing a staff member calling him a "jerk" and confirming this characterization when questioned by the resident. The resident stated he informed an LPN, who then reported it to the RN Infection Preventionist. The RN Infection Preventionist acknowledged awareness of a phone conversation in which someone called the resident a jerk but stated she did not know the full details and thought it might have been discussed in a care plan meeting. The Administrator reported being unaware of the situation until interviewed by the surveyor, at which time the incident had not been reported within the required two-hour timeframe. The facility also failed to complete and submit a required five-day follow-up report for a separate allegation of verbal abuse involving another resident. Record review showed that this resident had been admitted and later discharged to the hospital, and that a verbal abuse incident involving this resident had been reported to the state agency on 04/15/25. However, review of the facility’s list of reportable incidents for one year revealed no evidence that the corresponding five-day follow-up report was ever sent. The Administrator confirmed there was no record of that reportable incident or of a five-day follow-up. These failures were identified for two of two residents reviewed for abuse, with a facility census of 67.
Failure to Thoroughly Investigate and Document Alleged Financial Exploitation
Penalty
Summary
The deficiency involves the facility’s failure to ensure a thorough investigation and ongoing documentation of an allegation of misappropriation of resident property for one resident. Record review showed that the resident reported unknown charges on her debit card, and the facility initiated an investigation and notified OHFLAC, APS, the Ombudsman, and local law enforcement. Progress notes documented that law enforcement interviewed the resident, the resident cancelled her debit card, and she planned to obtain information from her bank. Notes also showed that the resident obtained bank statements, attempts were made to contact the investigating officer, and law enforcement later returned to obtain the resident’s banking information and ask additional questions. The facility’s 5‑day investigation report documented that the Administrator and DON reported the allegation, assisted the resident in obtaining bank statements, reviewed charges with her, identified the alleged perpetrator as the former roommate, separated the residents, and deactivated the debit card. The investigation was labeled inconclusive with law enforcement continuing the investigation, and a later Grand Jury subpoena was issued for the resident related to alleged fraudulent use of her debit card. Despite these initial steps, at the time of survey the facility was unable to provide additional documentation or evidence of follow‑up regarding the alleged misappropriation, including the total amount of funds involved, the outcome of the investigation, or any ongoing tracking of the allegation until requested by the State Agency. In interviews, the resident stated that her former roommate used her debit card without permission, estimated that approximately $800–$900 had been spent, and reported she had not received any updates about the situation. The BOM stated the facility did not have copies of the resident’s bank statements because they had been turned over to law enforcement and that law enforcement would not release information due to an ongoing investigation. In a follow‑up interview, the resident reported that no one from the facility had requested or attempted to review her bank statements, aside from law enforcement, until shortly before the interview when the BOM inquired, demonstrating that the facility did not maintain documentation necessary to determine the extent of the alleged misappropriation. A staff member later provided a written statement that they accompanied the resident to a Grand Jury proceeding related to fraudulent use of the debit card, but the facility still lacked internal documentation of the scope and outcome of the allegation.
Failure to Respond to Known Resident Elopement and Prolonged Unnoticed Absence
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from neglect by not responding to a known elopement. A cognitively intact resident, who had a BIMS score of 14 but had been deemed by the physician to lack capacity to make health care decisions, left the facility in the morning after having breakfast and receiving morning medications. The resident’s elopement risk evaluation score was 0, indicating low risk for elopement, and the MDS indicated no wander/elopement alarm was used less than daily. The resident’s care plan identified adjustment issues related to change in lifestyle and difficulty accepting placement, with interventions focused on coping and adjustment, but did not identify elopement risk prior to the incident. At approximately 9:00 AM, an activities assistant saw the resident walking outside down a public street near a store. The activities assistant contacted the social worker, who was the Manager on Duty, shortly thereafter to report the resident’s location. The activities assistant then clocked in for her shift around 9:03–9:05 AM. Despite this report, no effective action was taken by facility staff at that time to verify the resident’s whereabouts, intervene, or initiate a search. The social worker later stated she did not realize anything was going on until early afternoon, explaining that she missed the information about the resident being at the store while she was talking with other residents during the phone call. During the period from roughly 9:15 AM to 1:55 PM, there was a delay in supervision and monitoring of the resident. The LPN assigned to the resident reported administering morning medications and exchanging pleasantries with the resident earlier that morning, consistent with the facility’s elopement timeline. The CNA assigned to the resident stated that the resident was in the room during breakfast, but when she entered the room around 10:30 AM to provide a snack to the roommate, the resident was not present and she assumed he was in the bathroom. At lunchtime, when the CNA did not see the resident, she assumed he was out smoking. The facility did not recognize the resident as missing or initiate search or recovery actions until approximately 1:30 PM, when the activities assistant reported that the resident was not present for a smoke break. The State Agency determined that staff had witnessed the resident outside the facility but failed to intervene or report effectively, and that the facility remained unaware of the resident’s absence for about 4.5 hours, creating an Immediate Jeopardy situation due to the resident being unsupervised in the community for an extended period. The resident later reported that he was attempting to travel to another town to attend to personal business, hitchhiking to a nearby city and then walking further when he found the bus station closed. He described being offered a ride and food by a man who drove him to a restaurant, where he was eventually picked up by someone from the nursing home. The State Agency concluded that the facility’s failure to act on the known elopement and to promptly identify and respond to the resident’s absence constituted neglect and placed the resident at immediate risk for serious harm or death.
Failure to Use Gait Belt During Restorative Ambulation Resulting in Resident Fractures
Penalty
Summary
The facility failed to provide care and services in accordance with professional standards of practice when a resident participating in Restorative Therapy ambulation was walked without a gait belt, contrary to therapy recommendations. Record review showed the resident experienced a fall and was sent to the emergency room with pain in both legs, where diagnostic imaging revealed an anterior apex angulated distal femur diametaphyseal fracture with impaction in the left femur and an impaction and comminuted anterior apex angulated fracture of the distal fifth metaphysis in the right knee, with osteopenia noted. The resident, who is blind and requires specific instruction when ambulating, had been transferred from therapy to Restorative with recommendations documented on an Excel spreadsheet to ambulate with a walker, gait belt, and wheelchair behind the resident, up to 70 feet, along with ROM and strengthening exercises. A physician’s order for a Restorative Nursing Program for ambulating and ROM was in place, with the expectation that Restorative staff would refer back to therapy’s recommendations for safety measures. Interviews confirmed that on the day of the fall, staff ambulated the resident without a gait belt. The PTA identified the location of the fall and stated that a gait belt had not been used while walking the resident. The DOR reported that therapy staff had always used a gait belt with this resident and that the recommendation to use a gait belt was communicated via the Excel spreadsheet used by Restorative Therapy to receive therapy orders and recommendations. The resident, who had a BIMS score of 15 and thus had capacity, stated that she became tired while walking with Restorative staff, that a wheelchair was behind her but not close enough, and that she fell hard; she reported that staff did not have a gait belt on her and believed that if a gait belt had been used, she would not have fallen so hard. The DON stated she was not aware of the Excel spreadsheet and confirmed that therapy recommendations were not carried over for Restorative Therapy to follow.
Failure to Revise Activity Care Plan After Significant Change in Condition
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident received ongoing opportunities to participate in meaningful activities consistent with her interests and preferences following a significant change in condition. The resident experienced a fall on 02/18/26, was sent to a local emergency room for pain in both legs, and diagnostic radiology revealed an anterior apex angulated fracture of the distal left femur with impaction and an impaction and comminuted anterior apex angulated fracture of the distal right femur metaphysis, with osteopenia noted. She was hospitalized for these fractures and returned to the facility on 02/24/26. A subsequent MDS with an ARD of 02/27/26 documented a significant change in status and indicated that it was important for the resident to do things with groups of people, participate in her favorite activities, and attend church services. Record review showed that the resident’s activity care plan, originally initiated in 2020 and revised multiple times through 03/03/2025, contained numerous interventions reflecting her preferences, including in-room visits, participation in food committee and resident council, church and religious services, group singing and cooking, gardening, pet visits, listening to religious/bluegrass/country music, watching TV and keeping up with the news, and engaging in favorite activities such as church, sewing, cooking, reading, and gardening. The care plan also noted her use of a wheelchair and need for accommodations for visual impairments. However, there were no new or revised activity interventions added to address her new non–weight-bearing status and functional limitations after the fractures, and no changes to the activity care plan were documented following the significant change in condition. During interview, the resident, who had decision-making capacity and a BIMS score of 15, reported that prior to the fall she had been able to stand, pivot, and walk with therapy, and that she had been active in resident council, church, and social activities. She stated that since her return from the hospital she could not get into her wheelchair, could not attend resident council meetings or church, and could not participate in the group activities she enjoyed. She reported that activity staff did not visit her very often and became tearful while describing her situation. The Director of Recreation confirmed that the resident had not attended group activities since returning from the hospital, was non–weight-bearing for 10 weeks, and that anything done with her was now in-room. The Director of Recreation also stated that the resident did not receive one-to-one visits “per se” and that social visits were not documented. Surveyors identified that only two one-to-one visits had been documented since the resident’s return from the hospital and that there was a significant decline in her activity participation without corresponding revisions to her care plan, which led to the finding of failure to provide consistent, individualized activity interventions and ongoing opportunities for meaningful activities.
Failure to Provide Required 30‑Day Written Discharge Notice
Penalty
Summary
The facility failed to provide a required 30‑day written discharge notice to a resident prior to discharge. A complaint was received by the State Agency stating that the resident was being discharged to a hotel and that the facility would pay for the first 28 days, after which the resident would be responsible for their own expenses. The complainant reported the resident had no income and uncertainty existed about how the resident would obtain food and medications. Record review showed that on one date, Social Services documented discharge planning discussions and a referral to the Take Me Home program at the resident’s request, and an assessment note indicated discharge planning documentation was completed. Further record review revealed that on the day of discharge, Social Services documented that the resident was discharged to a motel with home health services arranged, a wheelchair provided, medications supplied, and a follow‑up appointment scheduled. Nursing documentation from the same day showed the resident received education on medications, blood glucose monitoring, emergency response, and home health services prior to discharge. However, there was no evidence in the medical record that the resident was provided a written 30‑day discharge notice before leaving the facility. In an interview, the Social Worker, in the presence of the Administrator, confirmed that the resident had chosen discharge to a motel and that the facility paid for 28 days at the hotel and provided 14 days of medications, and also confirmed that a 30‑day discharge notice was not issued. The deficient practice had the potential to affect the resident by limiting the ability to adequately prepare for discharge and exercise rights regarding the discharge process.
Failure to Update Activity Care Plan After Significant Change in Condition
Penalty
Summary
The deficiency involves the facility’s failure to update an activity care plan following a resident’s significant change in condition and participation. The resident experienced a fall on 02/18/26, resulting in fractures to the left distal femur and right distal femur/knee, with osteopenia noted on diagnostic imaging. She was hospitalized and returned to the facility on 02/24/26. A subsequent MDS with an ARD of 02/27/26 identified a significant change in status. Despite this, the resident’s activity care plan, originally initiated in 2020 and revised multiple times through 03/03/2025, was not revised after the fall and significant change to reflect her new limitations and altered participation in activities. Prior to the fall, the resident had been able to stand, pivot, and transfer to her wheelchair, and was walking up to 100 feet with therapy. She was active in out-of-room activities, including Resident Council, food committee, parties, socials, church, and other group activities. After the fall, she reported that she now had a rod in her left leg, a brace on her right leg, and was non-weight bearing for 10 weeks, which prevented her from getting into her wheelchair and attending the activities she previously enjoyed. She expressed distress about no longer being able to attend Resident Council meetings, church, and family gatherings, and stated that activity staff did not visit very often and that she could not go out to the groups she liked. During the interview, she was observed to be tearful. Record review of activity participation from 01/01/2026 to the present showed that the resident had participated in out-of-room activities before the fall but had no out-of-room participation after her return from the hospital. The records also showed that since the significant change, she had only two documented one-to-one visits, both on 03/04/26. The Director of Recreation confirmed that the resident had not attended group activities since returning from the hospital and was non-weight bearing, and stated that anything done with her was now in-room. The Director also stated that social visits were not documented as one-to-one visits. Surveyors noted that there were no new or revised interventions on the activity care plan since 01/2025 despite the significant change in the resident’s condition and participation, and the Administrator and Director of Recreation confirmed that the documentation reflected this lack of update.
Failure to Adjust Activities Program After Resident’s Significant Change in Condition
Penalty
Summary
The deficiency involves the facility’s failure to provide an activities program that met the interests and needs of a resident who experienced a significant change in condition and activity participation. The resident, who was cognitively intact with a BIMS score of 15 and served as president of the Resident Council, sustained fractures to the left distal femur and right distal femur/knee area after a fall and was hospitalized. Diagnostic imaging showed an anterior apex angulated, impacted distal femur diametaphyseal fracture on the left and an impacted, comminuted anterior apex angulated fracture of the distal fifth metaphysis of the right knee, with osteopenia noted. After hospitalization, the resident returned to the facility and had an MDS with a significant change assessment, with Section F indicating that it was important for her to do things with groups of people, participate in favorite activities, and attend church services. Record review showed that prior to the fall and fractures, the resident participated in out-of-room activities, including Resident Council, food committee, parties, and socials. The activity care plan, originally created in 2020 and revised multiple times through early 2025, documented numerous preferences and important activities for the resident, such as in-room visits, participation in food committee, church, singing, cooking, gardening, going outside in good weather, pet visits, listening to religious and other music, watching TV, reading, and engaging in religious services and voting. The care plan also noted that it was important for her to engage in her favorite activities and to have opportunities to make choices related to meaningful activities. However, there were no new interventions added or changes made to the activity care plan after her significant change in condition and return from the hospital. Activity participation records from the beginning of the year through the time of survey showed that since her readmission from the hospital, the resident had no out-of-room activity participation and only two documented one-to-one visits, both on the same day. During interview, the resident reported that she could no longer stand, pivot, or get into her wheelchair, and that she was now unable to attend Resident Council meetings, church, or be around people as she had before. She expressed distress about missing family gatherings she had been working toward attending and stated that activity staff did not visit very often and that she could not go out to the groups she liked. The Director of Recreation confirmed that the resident had not attended group activities since returning from the hospital due to being non–weight bearing, that anything done with her was now in-room, and that social visits were not consistently documented. The Administrator and Director of Recreation acknowledged that documentation showed only two one-to-one visits and no updated interventions on the care plan since before the significant change, leading to the finding that the facility failed to provide a program of activities to meet this resident’s needs and interests after her change in condition.
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